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Evaluation of Nurse-led Integrated Care of Complex Patients Facilitated By Telemonitoring: The SMaRT Study

Nurse-led Integrated Care of Complex Patients Facilitated By Telemonitoring: The Safe, Managed, and Responsive Transitions (SMaRT) Study

This is a registered study tracked in the Sterling IMRES research watch. It is sponsored by University Health Network, Toronto and run by the investigators named in the registry, not by Sterling IMRES. Details come from ClinicalTrials.gov, last updated 1 June 2026.

Summary

The SMaRT study in Ontario, Canada, evaluates a model in which nurses coordinate the care of patients with multiple chronic conditions using home telemonitoring. Patients send home measurements through the Medly platform so the care team can spot problems between visits. The study compares early death and readmission outcomes with usual care.

Objectives

  • Evaluate whether nurse-led integrated care supported by the Medly telemonitoring app reduces death or unplanned readmission at 30 days.
  • Support coordinated care for people living with several chronic conditions such as heart failure, COPD, diabetes and hypertension.

Methodology

Study design
Non-randomized, parallel assignment, open label, primary purpose: health services research
Conditions
Heart Failure，Congestive; Mental Health (Depression); Diabetes Mellitus; Chronic Obstructive Pulmonary Disease; Hypertension
Interventions
Medly (device)
Primary outcome
Death and/or all-cause unplanned readmission
Sample size
350 participants (estimated)
Locations
Canada

Team

0

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